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International Journal for Quality in Health Care Advance Access originally published online on January 20, 2009
International Journal for Quality in Health Care 2009 21(2):119-129; doi:10.1093/intqhc/mzn059
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© The Author 2009. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

Using quality indicators to improve hospital care: a review of the literature

Maartje De Vos1,2, Wilco Graafmans2, Mieneke Kooistra2, Bert Meijboom1,3, Peter Van Der Voort4 and Gert Westert1,2

1 Department of Tranzo, University of Tilburg, PO Box 90153, Tilburg 5000 LE, the Netherlands
2 Centre for Prevention and Health Services Research, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
3 Department of Organization and Strategy, University of Tilburg, PO Box 90153, Tilburg 5000 LE, the Netherlands
4 Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

Purpose. To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care.

Data sources. A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008).

Study selection. Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care.

Data extraction. Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care.

Results. A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan.

Conclusion. Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.

Keywords: quality indicators, quality improvement, quality measurement, implementation strategy, hospital care

Address reprint requests to: Maartje de Vos, E-mail: m.l.g.devos{at}uvt.nl

Accepted for publication November 12, 2008.


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